Provider Demographics
NPI:1114096047
Name:EDGAR C RODRIGUEZ HEREDIA
Entity Type:Organization
Organization Name:EDGAR C RODRIGUEZ HEREDIA
Other - Org Name:GLORIED AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-262-0501
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627-0566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:C20 CALLE 4
Practice Address - Street 2:URB DEL CARMEN
Practice Address - City:CAMUY
Practice Address - State:PR
Practice Address - Zip Code:00627-2843
Practice Address - Country:US
Practice Address - Phone:787-262-0501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTC-AMB2083416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0059392Medicare ID - Type UnspecifiedAMBULANCE SERVICE